DESARROLLO DE LAS ACTIVIDADES

• the diagnosis and any co-existing mental health conditions • short-term goals for treatment

• long-term goals for treatment

• situations that trigger distress or increase risk

• self-management strategies that reduce stress and risk

• strategies that have been used in the past with the aim of reducing distress, but were not helpful or made things worse

• who to contact in an emergency (see information on crisis planning in Section 8.5.3)

• health professionals, services and agencies involved in the person’s treatment and their roles • all other people helping with the person’s treatment (e.g. family, partner, carers or friends), including

their role in supporting the person • the planned review date

• who has a copy of the plan (list people and services).

Adapted from Project Air Strategy Treatment guidelines for personality disorder 182

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8.5

Assessing and managing risk of self-harm or suicide

8.5.1 Risk assessment for a person with BPD

General principles of psychiatric risk assessment apply when considering risk in people with BPD. However, clinicians treating people with BPD need to be aware of other factors that apply to people with BPD and should be taken into consideration.

Many people with BPD live with persistent thoughts of suicide. Chronically suicidal people (whether or not they have BPD) can think about or attempt suicide over the course of many years.264 _{Problems often begin in childhood or adolescence.}264, 265 _{Eventually, suicidality might} become part of a person’s ongoing experience, unlike in people who experience temporary suicidal thoughts associated with depression. Some people with BPD may repetitively harm themselves in potentially lethal ways (sometimes relying on being rescued by another person), and are at high risk for accidental death over long periods of time.

A person with BPD may live with persistent thoughts of self-harm, but also experience acute self-harming impulses from time to time. Some people with BPD use self-harm as a way of regulating their emotions. This practice does not mean they are suicidal, especially if the pattern of self-harm is consistent over time. Self-harm and suicidal behaviours may co-occur in a person with BPD. Clinicians should try to distinguish these, if possible.266

Suicide attempts by people with BPD may be planned or impulsive. Some people with BPD use threats of suicide to communicate their distress to other people with whom they have a close interpersonal relationship, or to their therapist.266 _{Once a trusting therapeutic relationship} is established, a person with persistent suicidal thoughts might disclose risk factors that require intervention, such as stockpiling of medicines intended for overdose.

Risk of self-harm or suicide fluctuates over time, so risk assessment should be ongoing. A thorough risk assessment for a person with BPD should be conducted:

• when the person first contacts a health service

• when the person begins a course of structured psychological therapy (see Section 5.1) • during a crisis

• if the person develops another mental illness (e.g. a substance use disorder, depression or psychosis)

• if the person’s psychosocial status changes

• at transitions between services or discharge from a treatment plan • when the BPD management plan is being reviewed or altered. A risk assessment should aim to identify changes in the following:182, 266 • pattern of suicidal behaviours

• self-harm behaviours, distinguishing high-lethality self-harm from low-lethality self-harm, and the pattern of self-harm behaviours

• co-occurring mental illness or substance use • the person’s sources of psychosocial support

In addition to special indicators of suicide risk in people with BPD (Table 8.4), clinicians should consider indicators of suicide risk that apply to the general population, including people with BPD. In general, suicide risk is increased if a person:182

• has a clear plan for suicide

• intends to use a method that is actually lethal

• has access to the intended means and it is feasible for them to carry out their plan • does not hope to be rescued during the planned suicide attempt

• expresses feelings of hopelessness about their future • has delusions that make them believe they must die • has co-occurring depression or a substance abuse problem • is not supported by a strong social network.

The clinician should also assess whether the person’s behaviour may constitute a risk of harm to others, including dependent children.

All these factors should be considered when assessing the person’s immediate and ongoing risk of suicide (Table 8.4 and Figure 8.1).

Table 8.4 Indicators of increased suicide risk in people with BPD

Factors associated with increased suicide risk, compared with previous level of risk, include:182, 266-276

• changes in usual pattern or type of self-harm (Figure 8.1)

• significant change in mental state (e.g. sustained and severe depressed mood, worsening of a major depressive episode, severe and prolonged dissociation, emergence of psychotic states)

• worsening in substance use disorder

• presentation to health services in a highly regressed, uncommunicative state

• recent discharge following admission to a psychiatric facility (within the past few weeks) • recent discharge from psychiatric treatment due to violation of a treatment contract

• recent adverse life events (e.g. breakdown or loss of an important relationship, legal problems, employment problems or financial problems).

Other factors associated with increased risk of suicide include: • co-occurring mental illness

• antisocial or impulsive personality traits or a co-occurring antisocial personality disorder • history of childhood sexual abuse, especially incest and prolonged abuse

• number and lethality of previous suicide attempts • experiences of loss in childhood.

8.5.2 Risk management for a person with BPD

Threats of suicide by people with BPD should always be taken seriously.

Managing the risk associated with chronic suicidality is different from managing risk associated with acute suicidality.264 _{In chronically suicidal people, active attempts to prevent suicide, such as} hospital admission and close observation, may be unhelpful or even escalate risk.277, 278 _{It may be} necessary to tolerate long-term suicide risk.264, 266 _{The person may be helped by learning to regulate}

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intense emotions, to curb impulsivity, and to build up a meaningful way of life.264 _Chronically suicidal people recover when their quality of life improves.

Among people who self-harm, an appropriate response to identified risks is based on frequent review to detect changes in the pattern (including frequency, type and level) of risk (Figure 8.1).266

Figure 8.1 Estimating probable level of suicide risk based on self-harm behaviour

High